In the surgical field, instruments, devices or methods are used in order to examine the interior of living organisms and/or to use for operative interventions. Among the surgical instruments are all medical instruments which are principally used in surgery. This also includes surgical instruments for the ligation or other alternative compression of duct- or tube-shaped body parts, preferably of blood vessels. Such surgical instruments are associated with the range of gripping or respectively clamping instruments and are available in a great variety of types and are sufficiently known. Gripping or respectively clamping surgical instruments are used for example in interventions in cardiac, thoracic and vascular surgery. In cardiac and thoracic surgery, usually an open operation is carried out in which, by opening up the thorax, access to the heart is created. The access takes place generally by means of a median sternotomy, wherein for opening the ribcage a longitudinal incision, approximately 25 cm long, is produced through the breastbone. In thoracotomy, the surgical opening of the thorax takes place by an intercostal incision, i.e. by a small incision into the intercostal space. The opening produced by the sternotomy or thoracotomy is held free by a rib retractor, which is used for expanding the ribcage and keeping it open. The opening serves as an access for the surgeon for operative interventions. The interventions on the organic body parts then take place by means of a plurality of different surgical instruments through the opening which has been produced in the ribcage. If, for example, the heart of the patient is exposed, various catheters, cannulas and clamps are applied directly onto the heart and the large blood vessels. Typically, the aorta is occluded with a vascular clamp around the ascending aorta, in order to isolate the coronary arteries from the remainder of the arterial system, wherein here occluding is understood to mean the gripping, compressing, clamping and holding of a vessel. The surgical instruments which are necessarily used reduce the body opening and therefore impede the activity of the surgeon in his field of vision. In addition, owing to the size of the opening, the tissue damage which has occurred and the operative trauma, a quick healing process is not to be expected in the patient.
Medical instruments of this type are known from the prior art. In particular, the gripping and clamping surgical instruments in the various types of construction and embodiments have proved to be successful as surgical instruments in many cases in operative interventions. These instruments have the advantage that the jaw parts or respectively the branches distribute the closing pressure in any desired position uniformly over the width of the vessels which are to be clamped.
DE 7139469 already shows a vascular clamp with two branch parts connected to one another in a pivotally movable manner about an axis. These branch parts are movable by pivotal movements for the closing and opening of the jaw, in a direction facing one another or respectively facing away from one another. By the connection of the jaw parts with the branch parts via a known parallel guide, it is achieved that the jaw parts, on the movement of the branch parts in a direction facing one another, or away from one another, are always moved parallel to one another, wherein the jaw parts are detachably connected with the branch parts. The parallel guide is constructed such that each jaw part with a branch part is pivotable about an axis lying on the side of the pivot axis of the branch parts facing away from the grips of the branch parts and at a distance therefrom, and is connected with the other branch part on the side of the pivot axis of the branch parts facing the grips of the branch parts and at a distance therefrom by means of a pin guided in a slot. This vascular clamp concerns a so-called opening and closing scissor-shaped clamping forceps. Such a clamping forceps consists basically of three regions, an operating means, a shaft part and a handling part. The lever mechanism of the vascular clamp consists in that, when the branch parts are moved towards one another or away from one another, the jaw parts are then moved towards one another by a path length corresponding to the reduction of the parallel guide, wherein the jaw parts always remain in their position parallel to one another. This embodiment of a vascular clamp does not, however, fulfil the requirements placed on it from minimally invasive surgery. On the one hand, a continuous adjustment of the jaw parts is absent, whereby a uniform clamping can be made possible with as little traumization of the tissue as possible, and on the other hand the embodiment does not correspond to that of a space-saving type of construction, which promotes an operative intervention in the access to the interior of the body. A separation of the vascular clamp into several components or respectively an ability of the vascular clamp to be dismantled between the jaw parts and the branch parts during the operation is not possible.
A further development of the above-mentioned vascular clamp, in particular for endoscopy, is disclosed in the prior art by DE 44 12 171 A1. In this embodiment, the movable jaw part is connected via a parallelogram-like articulated connection with the holder, which is formed in a fork-shape. Both jaw parts are moved continuously from an opened and/or closed position of use, parallel to the longitudinal axis of the holder. In addition, the front jaw joints and rear jaw joints are connected with a holder. Here, the front jaw joints have a shared axis via a front articulation- and retaining axis, close to the end of the holder, wherein both front jaw joints overlap one another. Furthermore, the front jaw joints, on closing of the jaw parts, can dip into the latter. The rear jaw joints are fastened on the holder jointly via a rear articulation axis, wherein the articulation axis is displaceable. Here, the rear articulation axis is provided with an opening for guiding through a tension- and pressure element, wherein the rear jaw joint engages into a groove by means of a rear jaw articulation axis. Proceeding from a hand grip, a tension- and pressure element runs through a sleeve-shaped operating element into the holder and terminates there at a rod articulation axis. The rod articulation axis is guided in a slot of the holder and is connected via tension- and pressure elements with the lever-shaped front jaw joints. The lever mechanism of the vascular clamp consists in that the front and rear jaw joints can be displaced in the manner of a parallelogram in the grooves of the jaw parts and in the groove of the fork-shaped holder, wherein the jaw joints on the one hand, on closing of the jaw parts, dip between the forks of the holder, and on the other hand into the jaw parts. By a movement of the tension- and pressure element, a displacement of the rod articulation axis takes place into a slot of the holder, whereby the jaw parts open or close. The parallelogram-like and continuous adjustment of this vascular clamp is regarded as obvious prior art. A disadvantage in this embodiment of an endoscopic instrument is the non-space-saving type of construction, which does not promote an operative intervening in the access to the interior of the body and does not reduce the number of instruments lying in the body opening. This means that the ability of the surgical instrument to be dismantled does not exist during usage, because a separation of the jaw part (operating instrument) from the holder (shaft part and handling part) is not possible during the operation.
The ability of a surgical instrument to be dismantled is disclosed in DE 197 19 090 A1. The concern here is with a minimally invasive surgical instrument which is able to be dismantled with jaw parts (branches) forming an operating instrument (operating means) for the gripping, holding and/or clamping of organs for surgical minimally invasive interventions, wherein the jaw parts, for closing and opening the operating instrument, are movable in a parallel manner towards one another and away from one another. The moving of the jaw parts in a parallel manner towards one another and away from one another takes place via two pairs of cranks respectively comprising an outer crank and an inner crank, which form an antiparallel crank gear in the form of a so-called double parallelogram linkage. A rotary movement of a worm gear is implemented by a translatory movement of the crank gear, wherein to carry out the parallel displacement of the jaw parts, the crank gear or a sliding block guide and a push- and pull element connected therewith is used. This instrument is able to be dismantled during use or respectively during the operation. To carry out the capability of being dismantled, the operating instrument (operating means) and the carrier instrument (shaft part) comprise coupling means which interact, wherein the coupling means form a coupling connection, also detachable during the use of the instrument, between the operating instrument (operating means) and the carrier instrument (shaft part). The coupling means comprise a push shaft and an instrument insert, see Claim 11 in this respect. The disadvantage of the instrument is to be found during handling. The disadvantage consists in the coupling ability of the coupling means during the use of the operating instrument (operating means) to separate the latter from the instrument shaft (carrier instrument) and to bring them together again. To produce the connection between the operating instrument and the instrument shaft or respectively carrier instrument, the centre axis of the operating instrument and the centre axis of the carrier instrument must be aligned with one another. This is as good as never the case during the operative use, because the vessels are relatively soft and movable, whereby the operating instrument and therefore its centre axis take up a position which does not coincide with the centre axis of the introduced carrier instrument. Furthermore, it is disadvantageous that the production of such an operating instrument, of such a carrier instrument and of such an instrument grip, is very sophisticated owing to the technical complexity, whereby the production costs of the entire instrument are too high. These high production costs can also be explained by the multiplicity of the required individual parts of the instrument. A further disadvantage consists in that the multiplicity of individual small parts can lead to be clamp having cavities, recesses etc., which can easily become contaminated during the use of the instrument in an operation, whereby the functioning of the instrument is impaired and safety can no longer be guaranteed.
A further surgical clamping system with a clamp, which has two jaw parts, which can be opened and closed reciprocally parallel to one another, and which are able to be actuated relative to one another from a completely open position into a completely closed position and have a detachable supply- and removal device with a bayonet connection, can be seen from DE 602 11 044 T2 an DE 602 24 460 T2. The introducing or removing of the clamp from the interior of the body takes place via an actuating member which cooperates with the supply- and removal device, wherein the clamp has a screw/nut drive or a worm drive, which are in engagement with the proximal ends of the jaw parts. In the screw/nut drive, the screw is coupled permanently with a push-pull rod which is in engagement with the jaw part by means of a joint. A rotating of the nut brings about an axial displacement of the screw, which pushes or pulls the push-pull rod. If the nut is replaced by a worm drive and the screw is replaced by a toothed rack, the gear system is a worm gear. In these instruments, as in the previously mentioned instrument from DE 197 19 090 A1, the coupling ability of the coupling means to separate an operating instrument from the instrument shaft during use and to receive it with this again is also beset with substantial disadvantages. The disadvantages consist in the handling of the instrument which result from the technical embodiment of the bayonet connection. To produce the connection between the operating instrument and the instrument shaft or respectively carrier instrument, the centre axis of the operating instrument and the centre axis of the carrier instrument must be aligned with one another. However, this does not exist during the operative use, and in the removal, because the clamp used in the interior of the body takes up a position in which the centre axis of the operating instrument does not coincide with the centre axis of the carrier instrument. It can be seen how complicated the removal of a clamp is from the following description. When the introduced clamp is no longer required, the supply- and removal device can be introduced again into the site of the operation, and with the use of an additional gripping means the clamp is held so as to be immobile. The distal end of the hollow shaft is then slipped over the proximal end of the clamp, and the handle is simultaneously pressed and rotated, so that the bayonet pins come into engagement with the bayonet. Whilst the handle is being held, the actuating member is introduced into the proximal end of the handle and guided through the hollow shaft and simultaneously rotated in the hollow shaft until the distal end penetrates into the slot of the nut and comes into engagement therewith, at which moment the detent comes into engagement with the groove and locks the actuating member in situ. The button is then rotated, whilst the handle is held immobile, in order to open the jaw part of the clamp. The clamp can now be removed from the tissue. From this description, the complex handling can be seen which is necessary to remove a clamp, and which is only possible with an additional instrument (gripping means), which holds the clamp immobile, so that the supply- and removal device can be connected with the clamp. A further disadvantage of the clamp consists in that in the case of the small parts of the worm gear, it can lead to the cavities, recesses, teeth etc. easily being able to be become contaminated, whereby the functioning of the instrument is impaired and the safety during a use of the instrument in an operation can no longer be guaranteed. A further disadvantage consists in the technical embodiment of the surgical clamp, which entails high costs in production.
EP 2 335 609 A1 is regarded as the nearest prior art in the continuous adjustment of a jaw part and the ability of a surgical instrument to be dismantled. EP 2 335 609 B1 discloses a surgical instrument which is able to be dismantled and completed. The surgical instrument which is able to be dismantled comprises a vascular clamp consisting of an operating instrument (operating means) with two branches, a supply- and removal device as carrier instrument, which consists of an operating arrangement and an actuating tool (handling part) with an instrument grip. This surgical instrument, owing to its simple ability to be dismantled during use or respectively during the operation, is used in minimally invasive surgery. The vascular clamp is gripped by means of a simply detachable operating arrangement, wherein an actuating tool, able to be pushed in and out, can open and close the movable branch of the operating means. For this, the vascular clamp contains a coupling arrangement and a continuous adjusting arrangement. For gripping or respectively receiving, and for releasing or respectively separating the vascular clamp from the operating arrangement (carrier instrument), the operating arrangement contains a gripping arrangement and has a fixing device, whereby a detachable connection between the vascular clamp and the operating arrangement can be produced in a simple manner. The coupling arrangement and the gripping arrangement form the coupling means which interact, wherein the coupling means form a coupling connection between the operating instrument (operating means) and the operating arrangement (the carrier instrument) which is also able to be detached during the use of the instrument. The actuating tool (handling part) with instrument grip engages into the adjusting arrangement of the vascular clamp for the continuous opening and closing of the branch. The disadvantage of this embodiment of the minimally invasive surgical instrument consists in that the jaw parts (branches) forming for the closing and opening of the operating instrument (operating means) are not movable in a parallel manner towards one another and away from one another, but rather operate according to the functional principle of a scissors, whereby a uniform gripping, holding and/or clamping of organs for surgical minimally invasive interventions is not possible.